Comparison of medial and anterolateral approaches for minimally invasive plate osteosynthesis in extra-articular distal tibial fractures

Aims: Extra-articular distal tibial fractures remain difficult injuries to treat because stable fixation must be achieved without compromising the surrounding soft tissues. Although minimally invasive plate osteosynthesis (MIPO) has become a widely accepted treatment strategy, evidence directly comparing medial and anterolateral plating techniques remains limited. The study aimed to compare clinical and radiographic outcomes between the two minimally invasive approaches. Methods: Medical records of 146 patients treated for distal tibial fractures between June 2019 and May 2024 were retrospectively screened. After excluding 35 patients who did not meet the eligibility criteria and 25 patients with insufficient follow-up, 86 patients with AO/OTA 43-A extra-articular distal tibial fractures treated using MIPO were included in the final analysis. Patients were allocated according to the surgical approach used for fixation: medial plating (M group, 48 patients) or anterolateral plating (AL group, 38 patients). Demographic data, fracture characteristics, radiographic union, postoperative complications, and functional outcomes assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were analyzed and compared. Results: Patients treated with the medial approach were significantly older than those treated with the anterolateral approach (44.6±16.2 vs. 38.5±5.4 years; p=0.017). Mean follow-up duration was 24.1±8.2 months in the M group and 22.5±8.1 months in the AL group (p=0.379). Mean time to union was 21.8±4.1 and 20.6±4.6 weeks, respectively (p=0.21), and mean AOFAS scores were 83.5±7.7 and 85.0±8.6, respectively (p=0.397). Likewise, no significant differences were observed in superficial or deep infection, malunion, nonunion, or overall complication rates. Implant-related irritation developed in 7 patients (14.6%) in the M group and in none of the patients in the AL group (p=0.016). Conclusion: Both medial and anterolateral MIPO techniques achieved satisfactory fracture healing and comparable functional outcomes. However, implant irritation was less frequent with anterolateral plating.